E & M CPT® CODING REVIEW AND AUDIT TOOL
This E & M CPT® Coding Review and Audit Tool is intended for use by medical professionals and coding experts to review the accuracy of coding and/or the adequacy of medical record documentation of Evaluation and Management services. The tool can be used to investigate specific encounters or to profile the coding and documentation patterns of individual physicians. If used for physician profiling, a random sample of encounters should be reviewed. We recommend a sample size of at least 10 encounters.

The E & M CPT Coding Review and Audit Tool calls for information as documented in the medical record for the encounter and assigns a CPT code based on this information. If this code differs from the code that was billed for the encounter, a coding and/or documentation problem (or a problem pattern) has been revealed. Further investigation and corrective action can then be undertaken as part of the practice's compliance program.

MDTools has tested and used this E & M CPT Coding Review and Audit Tool extensively, and we believe that will provide reliable and accurate results.

CPT Coding Review Audit Tool

Date of Visit

Initial Client E&M Code

Chart ID

ICD9 Reference

Select one of the following:

Is Chief Complaint documented?

1.

HISTORY

( Check ALL elements documented for parts A, B, and C.)

A.

History of Present Illness(HPI)

( Describes the development of patient's illness.)

Location

Quality*

Severity

Duration

*Quality=the special attribute which makes it unlike anything else

Timing

Context*

Mod Factors

Signs & Symptoms

*Context=interrelated conditions in which exists or occurs.

Please list any chronic or inactive conditions that were addressed during this visit:

Detailed exam is defined as an "Extended" examination. Verify with your medicare carrier its definition of "Expanded" versus "Detailed." If carrier
specifies "Detailed" is 5-7 areas or systems, choose the "Detailed" option in the dropdown box.

Select your exam form:

Notes on Exam

3.

MEDICAL DECISION MAKING

A.

PRESENTING PROBLEMS

Identify the problems mentioned in record.
Enter the # of problems in each category in column 2
( note the maximum number of problems recognized in "self-limiting"
and "New problem" categories). Do NOT categorize the problems if the
encounter is dominated by counseling or coordination of care and
the duration of time is not specified (if this is the case, enter 3
for the Total).

PROBLEM CATEGORIES

NUMBER

POINTS

SCORE

Self-Limiting or minor; stable/improving (Max 2)

1

Established problem; stable/improved

1

Established problem; worsening

2

New problem; no additional work up planned (Max 1)

3

New problem; additional work up planned

4

B.

TYPE OF DATA

Review each category of data below and circle the number in the points column if applicable. Enter the Total Number
of Circled points.